Abstract
Injectable urethral bulking agents composed of synthetic and biological biomaterials are minimally invasive treatment options for stress urinary incontinence (SUI). The development of an ideal urethral bulking agent remains challenging because of clinical concerns over biocompatibility and durability. Herein, the mechanical and biological features of injectable urethral biomaterials are investigated, with particular emphasis on their future potential as primary and secondary treatment options for SUI. A literature search for English language publications using the two online databases was performed. Keywords included “stress urinary incontinence”, “urethral bulking agent” and “injectable biomaterial”. A total of 98 articles were analysed, of which 45 were suitable for review based on clinical relevance and importance of content. Injectable biomaterials are associated with a lower cure rate and fewer postoperative complications than open surgery for SUI. They are frequently reserved as secondary treatment options for patients unwilling or medically unfit to undergo surgery. Glutaraldehyde cross-linked bovine collagen remains the most commonly injected biomaterial and has a cure rate of up to 53 %. Important clinical features of an injectable biomaterial are durability, biocompatibility and ease of administration, but achieving these requirements is challenging. In carefully selected patients, injectable biomaterials are feasible alternatives to open surgical procedures as primary and secondary treatment options for SUI. In future, higher cure rates may be feasible as researchers investigate alternative biomaterials and more targeted injection techniques for treating SUI.
Similar content being viewed by others
Abbreviations
- ISD:
-
Intrinsic sphincteric deficiency
- MMP:
-
Matrix metalloproteinase
- SUI:
-
Stress urinary incontinence
References
Leach GE, Dmochowski RR, Appell RA, Blaivas JG, Hadley HR et al (1997) Female stress urinary incontinence clinical guidelines panel summary report on surgical management of female stress urinary incontinence. The American Urological Association. J Urol 158:875–880
Kulseng-Hanssen S, Husby H, Schiotz HA (2008) Follow-up of TVT operations in 1,113 women with mixed urinary incontinence at 7 and 38 months. Int Urogynecol J Pelvic Floor Dysfunct 19:391–396
Isom-Batz G, Zimmern PE (2009) Collagen injection for female urinary incontinence after urethral or periurethral surgery. J Urol 181:701–704
Keegan PE, Atiemo K, Cody J, McClinton S, Pickard R (2007) Periurethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev CD003881
Bedir S, Kilciler M, Ozgok Y, Deveci G, Erduran D (2004) Long-term complication due to dextranomer based implant: granuloma causing urinary obstruction. J Urol 172:247–248
Henly DR, Barrett DM, Weiland TL, O’Connor MK, Malizia AA et al (1995) Particulate silicone for use in periurethral injections: local tissue effects and search for migration. J Urol 153:2039–2043
Hurtado E, McCrery R, Appell R (2007) The safety and efficacy of ethylene vinyl alcohol copolymer as an intra-urethral bulking agent in women with intrinsic urethral deficiency. Int Urogynecol J Pelvic Floor Dysfunct 18:869–873
Delancey JO, Ashton-Miller JA (2004) Pathophysiology of adult urinary incontinence. Gastroenterology 126:S23–S32
Petros PE, Woodman PJ (2008) The integral theory of continence. Int Urogynecol J Pelvic Floor Dysfunct 19:35–40
Kushner L, Mathrubutham M, Burney T, Greenwald R, Badlani G (2004) Excretion of collagen derived peptides is increased in women with stress urinary incontinence. Neurourol Urodyn 23:198–203
Cardozo L (2005) Neurobiology of stress urinary incontinence: new insights and implications for treatment. J Obstet Gynaecol 25:539–543
Falconer C, Ekman-Ordeberg G, Hilliges M, Johansson O (1997) Decreased innervation of the paraurethral epithelium in stress urinary incontinent women. Eur J Obstet Gynecol Reprod Biol 72:195–198
Kerr LA (2005) Bulking agents in the treatment of stress urinary incontinence: history, outcomes, patient populations, and reimbursement profile. Rev Urol 7 [Suppl 1]:S3–S11
Toozs-Hobson P, Al-Singary W, Fynes M, Tegerstedt G, Lose G (2012) Two-year follow-up of an open-label multicenter study of polyacrylamide hydrogel (Bulkamid®) for female stress and stress-predominant mixed incontinence. Int Urogynecol J 23:1373–1378
Klarskov N, Lose G (2008) Urethral injection therapy: what is the mechanism of action? Neurourol Urodyn 27:789–792
Dmochowski R, Appell RA (2003) Advancements in minimally invasive treatments for female stress urinary incontinence: radiofrequency and bulking agents. Curr Urol Rep 4:350–355
Faerber GJ (1996) Endoscopic collagen injection therapy in elderly women with type I stress urinary incontinence. J Urol 155:512–514
Herschorn S, Radomski SB, Steele DJ (1992) Early experience with intraurethral collagen injections for urinary incontinence. J Urol 148:1797–1800
Winters JC, Chiverton A, Scarpero HM, Prats LJ Jr (2000) Collagen injection therapy in elderly women: long-term results and patient satisfaction. Urology 55:856–861
Dmochowski RR, Appell RA (2000) Injectable agents in the treatment of stress urinary incontinence in women: where are we now? Urology 56:32–40
Kershen RT, Dmochowski RR, Appell RA (2002) Beyond collagen: injectable therapies for the treatment of female stress urinary incontinence in the new millennium. Urol Clin North Am 29:559–574
Schulz JA, Nager CW, Stanton SL, Baessler K (2004) Bulking agents for stress urinary incontinence: short-term results and complications in a randomized comparison of periurethral and transurethral injections. Int Urogynecol J Pelvic Floor Dysfunct 15:261–265
Pickard R, Reaper J, Wyness L, Cody DJ, McClinton S et al (2003) Periurethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev CD003881
Faerber GJ, Belville WD, Ohl DA, Plata A (1998) Comparison of transurethral versus periurethral collagen injection in women with intrinsic sphincter deficiency. Tech Urol 4:124–127
Murless B (1938) The injection treatment of stress incontinence. J Obstet Gynaecol Br Emp 45:521–524
Sachse H (1963) Treatment of urinary incontinence with sclerosing solutions. Indications, results, complications. Urol Int 15:225–244
Gonzalez Garibay S, Jimeno C, York M, Gomez P, Borruell S (1989) Endoscopic autotransplantation of fat tissue in the treatment of urinary incontinence in the female. J Urol (Paris) 95:363–366
Lee PE, Kung RC, Drutz HP (2001) Periurethral autologous fat injection as treatment for female stress urinary incontinence: a randomized double-blind controlled trial. J Urol 165:153–158
Lightner D, Rovner E, Corcos J, Payne C, Brubaker L et al (2009) Randomized controlled multisite trial of injected bulking agents for women with intrinsic sphincter deficiency: mid-urethral injection of Zuidex via the Implacer versus proximal urethral injection of Contigen cystoscopically. Urology 74:771–775
Dmochowski R (2004) Interventions and outcomes. What is important (and what is not)? J Urol 172:8–9
Hurtado EA, Appell RA (2009) Complications of Tegress injections. Int Urogynecol J Pelvic Floor Dysfunct 20:127, author reply 129
Ghoniem GM, Miller CJ (2012) A systematic review and meta-analysis of Macroplastique for treating female stress urinary incontinence. Int Urogynecol J doi: 10.1007/s00192-012-1825-9
ter Meulen PH, Berghmans LC, Nieman FH, van Kerrebroeck PE (2009) Effects of macroplastique implantation system for stress urinary incontinence and urethral hypermobility in women. Int Urogynecol J Pelvic Floor Dysfunct 20:177–183
Maher CF, O’Reilly BA, Dwyer PL, Carey MP, Cornish A et al (2005) Pubovaginal sling versus transurethral Macroplastique for stress urinary incontinence and intrinsic sphincter deficiency: a prospective randomised controlled trial. BJOG 112:797–801
Ghoniem G, Corcos J, Comiter C, Bernhard P, Westney OL et al (2009) Cross-linked polydimethylsiloxane injection for female stress urinary incontinence: results of a multicenter, randomized, controlled, single-blind study. J Urol 181:204–210
Mayer RD, Dmochowski RR, Appell RA, Sand PK, Klimberg IW et al (2007) Multicenter prospective randomized 52-week trial of calcium hydroxylapatite versus bovine dermal collagen for treatment of stress urinary incontinence. Urology 69:876–880
Bano F, Barrington JW, Dyer R (2005) Comparison between porcine dermal implant (Permacol) and silicone injection (Macroplastique) for urodynamic stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 16:147–150, discussion 150
Corcos J, Collet JP, Shapiro S, Herschorn S, Radomski SB et al (2005) Multicenter randomized clinical trial comparing surgery and collagen injections for treatment of female stress urinary incontinence. Urology 65:898–904
Lightner DJ (2002) Review of the available urethral bulking agents. Curr Opin Urol 12:333–338
Lightner D, Calvosa C, Andersen R, Klimberg I, Brito CG et al (2001) A new injectable bulking agent for treatment of stress urinary incontinence: results of a multicenter, randomized, controlled, double-blind study of Durasphere. Urology 58:12–15
Andersen RC (2002) Long-term follow-up comparison of durasphere and contigen in the treatment of stress urinary incontinence. J Low Genit Tract Dis 6:239–243
Lose G, Mouritsen L, Nielsen JB (2006) A new bulking agent (polyacrylamide hydrogel) for treating stress urinary incontinence in women. BJU Int 98:100–104
Kirchin V, Page T, Keegan PE, Atiemo K, Cody JD et al (2012) Urethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev 2:CD003881
Carr LK, Steele D, Steele S, Wagner D, Pruchnic R et al (2008) 1-year follow-up of autologous muscle-derived stem cell injection pilot study to treat stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 19:881–883
Conflicts of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Davis, N.F., Kheradmand, F. & Creagh, T. Injectable biomaterials for the treatment of stress urinary incontinence: their potential and pitfalls as urethral bulking agents. Int Urogynecol J 24, 913–919 (2013). https://doi.org/10.1007/s00192-012-2011-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00192-012-2011-9